Orthoptics for the busy The College of optometrist Optometrists - - PDF document

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The College of Optometrists

Welcome to our webinar

Orthoptics for the busy

• ptometrist

Professor Bruce Evans BSc (Hons) PhD FCOptom FAAO FEAOO

FBCLA DipCLP DipOrth Director of Research, Institute of Optometry

22 January 2020 1 Interactive CET point

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DISCLOSURE

Paid lectures & KOL/product feedback programmes:

Alcon, American Academy of Optometry (UK), Association of Optometrists, Birmingham Focus on Blindness, Black & Lizars, Central (LOC) Fund, Cerium Visual Technologies, College of Optometrists, Coopervision, ESRC, General Optical Council, Hoya, Institute of Optometry, International Institute for Colorimetry, Iris Fund for Prevention

• f Blindness, Johnson & Johnson, Leightons, London Vision Clinic, MRC,

Norville, Optos, Paul Hamlyn Trust, Perceptive, Scrivens, Specsavers, Thomas Pocklington Trust. Lecture content always my own

Author of Pickwell’s Binocular Vision Anomalies, editions 3-5 i.O.O. Sales Ltd markets IFS orthoptic exercises, which the speaker designed, and for which he receives a small royalty Director of a community optometric practice in Brentwood, Essex

PLAN

INTRODUCTION INVESTIGATION OF INCOMITANCY INVESTIGATION OF HETEROPHORIA INVESTIGATION OF HETEROTROPIA TREATMENT CONCLUSIONS

Full handout of slides from www.bruce-evans.co.uk For regular tweets on optometric research:

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OVERVIEW: CAVEAT

>5% of patients seeing community

• ptometrists have BV problems

Always look for pathology:

Neuro-optometric checks Pupils, discs, fields, strabismus, incomitancy, accommodation Check these things regularly

Don’t forget refraction Change management if not improving significantly Refer if still not improving Appropriate re-exam intervals (frequent)

Poll question 1

PLAN

INTRODUCTION INVESTIGATION OF INCOMITANCY INVESTIGATION OF HETEROPHORIA INVESTIGATION OF HETEROTROPIA TREATMENT CONCLUSIONS

Full handout of slides from www.bruce-evans.co.uk For regular tweets on optometric research:

CAUSES OF INCOMITANCIES

VASCULAR NEUROLOGICAL OTHER

Diabetes Hypertension Stroke Aneurysms Temporal arteritis Tumours Multiple sclerosis Myasthenia gravis Migraine Trauma Thyrotoxicosis Toxic Iatrogenic Idiopathic Underlined = more likely in elderly

Poll question 2

Motility test

Use reliable pen torch

Check nose not occluding

Really, three tests, so do three times:

1)

Observe corneal reflexes

2)

Cover test in peripheral gaze

3)

Ask about diplopia

Beware of reports of diplopia

May break down (in view of target, distance, fus. res.) May be variable May be confused

Know the muscle actions (RADSIN)

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ACTIONS OF SUPERIOR MUSCLES MOTILITY DIAGRAM

IO SO SR IR MR LR IO SO SR IR MR LR

Incomitancies: the bottom line

Some incomitancies are difficult to detect

If symptoms are suspicious, do cover testing in peripheral gaze Testing for cyclo-deviations detects SO palsies

Refer new or changing incomitancies In some long-standing cases, prescribing the prism required in the primary position may help

PLAN

INTRODUCTION INVESTIGATION OF INCOMITANCY INVESTIGATION OF HETEROPHORIA INVESTIGATION OF HETEROTROPIA TREATMENT CONCLUSIONS

Full handout of slides from www.bruce-evans.co.uk DISSOCIATED HETEROPHORIA fusional reserves motor fusion fusion lock sensory fusion COMPENSATED or NOT

• rthophoria

hyperphoria exophoria esophoria

5.00 4.00 3.00 2.00 1.00 0.00

1st appt. mean (TP & BE)

3.00 2.00 1.00 0.00

• 1.00
• 2.00
• 3.00

1st appt. difference (TP-BE)

1.0 1.2 1.4 1.6 1.8 2.0

Scale

Panesar & Evans, in preparation

Signs of decompensated phoria

Symptoms Poor cover test recovery

• Some information can be
• btained from recovery

movement, but

• No data on sensitivity &

specificity of this

• Cover test dynamics are

complex (Barnard & Thomson,

1995 Grade Description 1 rapid and smooth 2 slightly slow/jerky 3 definitely slow/jerky but not breaking down 4 slow/jerky and breaks down with repeat covering, or only recovers after a blink 5 breaks down readily after 1-3 covers Evans (2007) Pickwell’s Binocular Vision Anomalies

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KEY SIGNS OF DECOMP. PHORIA

Symptoms Poor cover test recovery Aligning prism (FD test) Low fusional reserve opposing phoria Sheard’s criterion Particularly useful for exophorias For esophorias, size and imbalanced fusional

reserves are relevant

For hyperphorias, size matters

ALIGNING PRISM: Mallett Unit

• aligning prisms/spheres to eliminate FD
• good foveal and peripheral fusion lock
• question set is important
• ask if a line ever moves
• Karania & Evans (2006)
• for symptomatic phoria:
• sensitivity 75%
• specificity 78%
• Jenkins, Pickwell,

& Yekta (1989)

aged 40 years and over under the age

• f 40 years

1-SPECIFICITY 1.0 .8 .6 .4 .2 0.0 1.0 .8 .6 .4 .2 0.0 1+ 1+ 2+ 2+ 3+ 3+

ALIGNING PRISM: Mallett Unit

• Maintain normal binocular vision
• Increase lighting, full field of view
• Use hand held loose prisms
• Minimum prism for alignment
• Re-normalise BV between prisms
• Prism dioptre steps: 0.5, 1.0, 2.0, 4.0

aged 40 years and over under the age

• f 40 years

1-SPECIFICITY 1.0 .8 .6 .4 .2 0.0 1.0 .8 .6 .4 .2 0.0 1+ 1+ 2+ 2+ 3+ 3+

Poll question 3

KEY SIGNS OF DECOMP. PHORIA

Poor cover test recovery Aligning prism Low fusional reserve opposing phoria Sheard’s criterion Particularly useful for exophorias For esophorias, size and imbalanced fusional

reserves are relevant, consider cycloplegia

For hyperphorias, check comitancy carefully

STEREOTESTS

www.bernell.com

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DISSOCIATED HETEROPHORIA fusional reserves motor fusion fusion lock sensory fusion STRABISMUS NOT COMPENSATED

PLAN

INTRODUCTION INVESTIGATION OF INCOMITANCY INVESTIGATION OF HETEROPHORIA INVESTIGATION OF HETEROTROPIA TREATMENT CONCLUSIONS

Full handout of slides from www.bruce-evans.co.uk For regular tweets on optometric research: sorted! yes e.g., Rx no REFER can I correct it? yes e.g., hypermetropia no REFER do I know the cause? yes any treatment needed? (probably not) no is it new or changing?

Strabismus: the bottom line for the busy optometrist

A M B L Y O P I A

Strabismus: the bottom line for the busy optometrist

sorted! yes e.g., Rx no REFER can I correct it? yes e.g., hypermetropia no REFER do I know the cause? yes any treatment needed? (probably not) no is it new or changing? A M B L Y O P I A

Poll question 4

PLAN

INTRODUCTION INVESTIGATION OF INCOMITANCY INVESTIGATION OF HETEROPHORIA INVESTIGATION OF HETEROTROPIA TREATMENT CONCLUSIONS

Full handout of slides from www.bruce-evans.co.uk For regular tweets on optometric research:

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TREATMENT OF AMBLYOPIA (a)

Many cases never require full-time occlusion

If 6/9 to 6/25, 2h occ. ≡ 6h If ≤ 6/30, 6h > 2h

Avoid full time occlusion for

• rthotropic anisometropia

Timings approximate

See patients frequently during the treatment of amblyopia, to begin with every 4-6 weeks

Flow chart based on review of recent RCTs in Evans et al. (2011; OPO) Many cases of amblyopia can be cured by refractive correction alone; 20% don’t need occlusion (Gibson, 1955; Pickwell, 1984; Stewart et al., 2004; West & Williams, 2011) Contact lenses are likely to be best in anisometropia (Evans, 2006)

Poll question 5

MOTOR DEVIATION: REFRACTIVE CORRECTION: OVERVIEW

• Mandatory in accommodative esotropia
• Also possible to treat convergence

excess with multifocals & exo- deviations with negative lenses

• limited by 4 factors

– angle of deviation – refractive error – accommodation – AC/A ratio

MOTOR DEVIATION: REFRACTIVE CORRECTION: SPECIFICS

• determine sphere that

– eliminates strabismus (no diplopia) – eliminates FD on Mallett Unit

• prescribe, try to reduce approx. every 3-6/12
• negative adds (Chen et al., 2016) and

bifocals/varifocals can work well

MOTOR DEVIATION: REFRACTIVE CORRECTION: CASE STUDY: D1542

• 11/5/96, female, age 8y, 1 headache a fortnight

– wearing full cyclo plus (c. +2.00, R=L) – cover test: D: 8 SOP N: 10 RSOT – with +2.00 add: N 4 RSOT with +2.50 add: N ortho

Date May 96 July 96 Mar 97 Jun 97 Sep 97 Jan 98 Apr 98 Jun 98 Sep 98 Add +2.50 +3.00 +2.50 +2.00 +1.75 +1.50 +1.00 +0.50 None

MOTOR DEVIATION: PRISMATIC CORRECTION: OVERVIEW

• preferred treatment in

small/moderate vertical deviations

• may also help in small/moderate

horizontal deviations if not amenable to refractive modification

• r exercises
• limited by angle of deviation /

cosmesis of prism

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MOTOR DEVIATION: PRISMATIC CORRECTION: SPECIFICS

• determine prism that

– eliminates strabismus (no diplopia) – eliminates FD on Mallett Unit

MOTOR DEVIATION: FUSIONAL RESERVE EXERCISES:

OVERVIEW

• preferred treatment in small/moderate horizontal deviations, if px co-
• perative
• Work well in those aged 11-19y, even if strabismic (Pickwell & Jenkins,

1982)

• in exo-deviations improve ability to converge
• in eso-deviations improve ability to diverge
• try to assess progress using a method different to the treatment technique
• mixed evidence from RCTs

– Scheiman & Gwiazda (2011) - intensive exercises better than push-up – CITT-ART trial – intensive exercises improve NPC & fusional reserves, but not symptoms (CISS) or reading

CONVERGENCE INSUFFICIENCY: SPECIFICS

Treatments (in order of increasing complexity) simple push up (bead on string if very remote) jump convergence push up with physiological diplopia jump convergence with physiological diplopia programme of exercises (e.g., Institute Free-space Stereograms) RCT shows intensive programme of exercises better than home push-up

Scheiman et al. (2005) results may be attributable to dose effect

“Whether synoptophore or jump vergence stereocards are used…the critical variable is the length of time it is maintained”

Vaegan (1979)

“Convergence exercises independent of accommodation were the most effective treatment”

Horwood & Toor (2014)

See standard textbooks for details on exercises (e.g., Pickwell’s Binocular Vision Anomalies)

Poll question 6

PLAN

SYMPTOMS INVESTIGATION OF INCOMITANCY INVESTIGATION OF HETEROPHORIA INVESTIGATION OF HETEROTROPIA TREATMENT CONCLUSIONS

Full handout of slides from www.bruce-evans.co.uk For regular tweets on optometric research:

CONCLUSIONS

Always be on the lookout for pathology refer if no significant improvement BUT pathology is very rare It is possible to treat amblyopia in optometric practice patients will need good instructions & regular checks Many comitant ocular motor anomalies are treatable plus for eso, minus for exo, & prisms are under-used treatments Vision therapy for convergence insufficiency is evidence- based, but there is a need for more research for other forms of vision therapy

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Q&A

Thank you

Thank you to everyone who attended, and all those who submitted a question this evening. A recording of this webinar and the follow-up podcast will be available on the College’s website soon.

FEEDBACK AND CET

FEEDBACK Your feedback helps us plan future member events. Let us know what you thought about this session at www.college-optometrists.org/BruceEvans-Feedback NEXT WEBINAR How to recognise diabetic retinopathy and manage your patients – 19 March 2020 https://www.college-optometrists.org/Webinar- DiabeticRetinopathy An email containing these links will be sent to you within the next hour.

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